Anticipated Impacts on Veterans Health Care This research is reasonably expected to improve Veteran-centered care by reducing barriers and providing enhanced support in the consultation request process between primary and specialty care. This research will also set up development of a toolbox, design strategies for an information decision support tool and policies for improved consultation management with the EHR. These contributions have great potential to improve patient outcomes by streamlining access to specialty care and ensuring greater efficiency, communication, and teamwork. Project Background More than a third of patients in the United States are referred to a specialist each year and more than half of outpatient visits are with specialists. Although the referral process between primary and specialty care is a core clinical process, it continues to be a long-standing source of frustration for providers. Recent research shows that one-third (36%) of all consult requests entered by Veterans Affairs (VA) primary care physicians (PCPs) are discontinued by specialty care services and returned. About half of the discontinued consults lack follow-up actions within 30 days. Furthermore, preliminary data from an HSR&D CDA (Saleem, PI), Circumventing Health IT: Identifying Patient Safety Risks (CDA 09-024-1), upon which the current study builds, identified multiple examples of workarounds, communication breakdowns, and redundancies in VA computerized consult management. Barriers to effective consultations, such as these, may result in delays in patient care and subsequently adversely impact the quality of medical care VA patient receive and patient outcomes. Project Objectives The objectives of this study are to: (a) identify barriers, facilitatos, and suggested improvements to the consultation request process and the mechanisms that specialty providers use to communicate findings to outpatient primary care providers; (b) characterize provider teamwork and communication exchanges between primary care providers and specialists, including communication breakdowns and effective communication strategies; and (c) develop and test process and EHR design changes for consultation management and compare those changes to the current consultation request process and EHR. Project Methods To achieve objectives (a) and (b), we propose a multi-method study that will include semi-structured interviews, ethnographic observation, and work sampling techniques at the Palo Alto VAMC (VISN 21) and Charleston VAMC (VISN 7) along with preliminary data already collected from the Indianapolis VAMC (VISN 11). To achieve objective (c), a usability simulation study will be conducted at the Indianapolis VAMC to test the performance of process and IT design changes (i.e., architecture, interface, decision support) meant to reduce barriers and improve performance with the computerized consults.